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How is disease detected?

spontaneous presentation
opportunistic case finding


Define screening

a sytematic attempt to identify an unrecognised condition via applying tests or asking questions, which can be done rapidly and cheaply, to distinguish between apparently well people who probably have the disease, or its precursor, and those who probably do not have it, and so identify people who are more likely to be helped than harmed by further tests or tment to reduce risk of disease or its complications


what is lead time bias?

example of an evaluation difficulty for screening programmes.
Refers to an early diagnosis falsely appearing to prolong patient survival, with screened patients seemingly surviving longer, when actually they live for same length of time, but spend longer knowing they have the disease, and so only appear to live longer as diagnosed earlier.


why does lead time bias occur?

once screening has detected a disease before the disease is clinically obvious, the finding out of the patient that they have a disease is brought forward and so the length of time told that they have left to live will be longer, than if the disease was only picked up when symptomatic as that would occur years later, and so there would be less time between detection and dying, althought they will still die at the same time, they just spend more time knowing they have the disease.


examples of evaluation of screening programmes difficulties?

lead time bias
length time bias
selection bias


why is finding a disease earlier NOT the primary objective of screening?

giving tment earlier may not improve disease outcome
tment earlier may produce harmful SEs
uneccessary anxiety and depression if find out they have the disease earlier in life and there is nothing that can be done to help them


screening purpose?

give better outcome when compared with finding something in the usual way


risks and benefits of AAA screening?

+ve: reduce risk of death from rupture by 1/2
-ve: coping with anxiety of having small AAA
QOL impaired when tment
tment can be complicated by death


criteria for screening programmes?



factors assoc with disease in order to have a screening programme?

important health problem- QOL, early mortality
epidemiology and nat history understood to know what category of people screening would be relevant to, and identify when it should be implemented
must have an early detectable stage
cost-effective primary prevention interventions must have been considered, and where possible implemented to reduce risk of disease develop e.g. quitting smoking to reduce LC risk before LC screening


characteristics of test for use in screening?

simple and safe
precise and valid, validity= sensitivity, specificity, PPV, NPV
acceptable to pop.
distribution of test values in pop. known
agreed cut-off level for when person will class as testing +ve
must be agreed policy on whom to investigate further


which screening programmes lack test acceptability?

colorectal cancer- having to use special toilet paper which is then sent off in the post for assessment
cervical cancer- smear, invasive procedure


characteristics of treatment in order to have a screening programme?

effective evidence based tment available
early tment must be advantageous- so not just bringing fward date of diagnosis, must be something beneficial to outcome by finding disease earlier
agreed policy on whom to treat
clinical management of the condition and patient outcomes should be optimised in H care providers before participation in screening programme


characteristics of the screening programme itself in order for screening to be implemented?

proven effectiveness e.g. RCT data
quality assurance for whole programme and not just test
facilities for counselling
facilities for diagnosis and tment
consider other options e.g. improving tment
opportunity costs- should money spent on screening be used on tment
decisions about parameters should be scientifically justifiable to the public
benefit should oweigh phys and psych harm


issues for patient if +ve screening test, but they don't have the disease?

uneccessary stress, anxiety, inconvenience- SEs of tment
direct costs
opportunity costs- resources consumed that could be used to treat people who actually have the illness
may be lower uptake of screening in future and greater risk of interval cancer= cancer which appears in interval between screening


issues for patient if -ve screening test, but they do have the disease?

false reassurance
possibly delay presentation with symptoms as patient been convinced by screening that they are at low risk of the disease and so symptoms which they may have associated with the disease and so caused them to present if they hadn't had screening, they may now choose to ignore as they don't believe they have the disease


advantages of screening?

produce a better outcome for the patient if the disease is detected early
provide reassurance to those patients who are true -ves


disadvantages of screening?

false +ves: uneccessary anxiety, exposure to tment SEs and invasive diagnostic techniques e.g. CAC- colonoscopy, divert money away from treating those people who actually have the illness
false -ves: inappropriate reassurance, present later with symptoms of disease, not given the diagnostic testing they may benefit from


why is length time bias an evaluation difficulty of screening programmes?

screening better at picking up slow-growing, unthreatening cases than aggressives, fast-growing ones, so disease detectable more likely to have a favourable prognosis, and may have never caused a problem had they not been detected by screeening anyway, and so may be curing those that don't need curing with false conclusion that screening is beneficial in lengthening lives of those found +ve, when in fact, the disease wouldn't have shortened their life anyway


why is selection bias an evaluation difficulty of screening programmes?

'healthy volunteer' effect- those people who have regular screening are likely to be healthier than the general pop anyway as likely to do other things that protect them from disease.


how could selection bias affected screening programmes be dealed with?

RCT as random allocation to screening programme rather than choice of individual to do something beneficial to their health which is more likely done by healthier people anyway


structural critiques of screening?

victim blaming- people must take responsibility for their own health, are all equally able to do this?
individualising pathology- not addressing underlying material causes of disease e.g. primary interventions, so focused on prevention at an individual level, more we could do at a societal (or structural) level to address some of the material causes


surveillance critiques of screening?

individ and pop increasingly subject to sureveillence
prevention part of wider apparatus of social control?- people requested to present themselves for surveillence


5 Ds of rationing in the NHS?

denial- range of services denied to patients e.g. reversal of sterilisation, infertility tment
deterrent- demands for hcare obstructed e.g. paying for a prescription or dental charges- people deterred from using a resource if they have to pay for it
delay- waiting lists
deflection- GPs deflect demand from secondary care
dilution- e.g. fewer diagnostic tests used or cheaper drugs-generic brand, just doing what you absolutely need


why we need priorities in NHS in terms of resources?

scarcity of resources, so demand outstrips the supply, and resources could be used in other ways
it must be clear and explicit who benefits from public expenditure- ethical reasons
need to be clear about whether spending is worth it


why is demand for NHS resources increasing?

pop demographics- ageing pop
costs of new technology
technological advances


what is implicit rationing?

allocation of resources through individual clinical decisions without the criteria for those decisions being explicit, and hence not based on defined rules of entitlement


what might be the benefit of implicit rationing?

more sensitive to complexity of medical decisions and the needs and personal and cultural preferences of patients


disadvantages of implicit rationing?

open to abuse e.g. not giving a patient tment if you don't like them
decisions based on perceptions of social deservingness e.g. 2 patients require chemotherapy for their lung cancer, but 1 is smoker and the other a non-smoker, so you give it to the non-smoker
can lead to inequities and discrimination
drs unwilling to engage


define explicit rationing

use of institutional procedures for the systematic allocation of resources within the healthcare system, so use of particular guidelines which have an evidence base behind them which is known


advantages of explicit rationing?

transparent, accoutable
opportunity for debate
use of evidence-based practice
more opportunities for equity in decision making


disadvantages of explicit rationing?

heterogeneity of patients and illnesses
very complex
patient and professional hostility
threat to clinical freedom
evidence of patient distress- it's made clear to the patient that a particular drug would likely be very effective for them but you're not going to prescribe it because it is unaffordable


Cost utility analysis: patient is 54 and diagnosed with peptic ulcer disease, she can expect to live till 77 without tment with a QOL=0.7 of perfect health. Tment A= life expect with a QOL of 0.95, and cost £50 annually. Tment B= life expect with a QOL of 0.80, and cost £30 annually. Which is more cost effective?

cost effectiveness= cost per QALY gained.
Without tment, QALYs= 23x0.7=16.1
A: total cost= 50x23=£1150, QALYs= 0.95x23= 21.85, QALYs gained= 21.85-16.1= 5.75, so cost per QALY gained=1150/5.75= £200

B: total cost= 30x23= £690, QALYs= 0.80x23=18.4, so gained= 18.4-16.1= 2.3, so cost per QALY gained= 690/2.3= £300

so Tment A is more cost effective, despite the cost annually being more, meaning that extra benefit is gained from extra cost


define cost minimisation analysis?

choose cheapest option as assume outcomes are equivalent, so focus on measurement is on costs, so only inputs, but outcomes rarely equivalent


what are the 4 types of economic evaluation?

cost minimisation analysis
cost effectiveness analysis
cost utility analysis
cost benefit analysis


define cost effectiveness analysis?

comparison between interventions which have a common health outcome e.g. recuction in BP, and compared in terms of cost per unit outcome e.g. cost per reduction. Want to know if extra benefit worth extra cost.


define cost utility analysis?

type of CEA, which focuses on quality of health outcomes produced or foregone e.g. QALY, so can compare interventions based on cost per QALY


define cost benefit analysis?

all inputs and outputs viewed in monetary terms (in relation to money), can allow comparison with interventions outside of hcare, methodological difficulties e.g. putting monetary value on non-monetary benefits such as lives saved. willingness to pay is often used but is also problematic as often undervalued, rather than what they would be willing to pay.


disadvantages of QALYs?

not distributing resources according to need, but according to benefits gained per unit of cost
technical problems with calculations
QALY may not embrace all dimensions of benefit, as values expressed by experimental subjects may not be representative
controversy about the values they embody
RCT evidence: comparison therapies may differ, length of follow-up, atypical care, atypical patient- may not be those that would benefit from intervention if excluded for ethical reasons, limited generalisability, sample sizes
statistical modelling may address some problems and areas of uncertainty


what is a QALY?

1 year of healthy life for 1 person


social constructionist critique of screening?

health and illness practices can be seen as moral- given meaning through particular social relationships


feminist critique of screening?

is screening more targeted at women than men? e.g. breast cancer, cervical cancer, seems to be overmedicalising women's bodies


difference between explanatory and aspirational models of dr-patient relationship?

explanatory: explain way the relationships work and what can go wrong
aspirational: describe how it ideally should be


roles of drs and patients argued by functionalist approach as what dr patient relationship is based on?

The ‘sick role’ is associated with the rights to be excused from obligations and to seek medical
attention, and with the duties to want to get well, not to abuse the role, and to cooperate with the
doctor in the healing process. The role of ‘doctor’ includes the duties to work in the interests of
patients, to be objective and non-discriminatory, and is associated with the entitlement to
autonomy, status and financial reward.


why are dr and patient roles important to allow relationship between the 2 to work?

There is an imbalance of power in the relationship, and patients are vulnerable. For the relationship
to work, doctors and patients must trust that each will abide by the rights and duties of these
socially prescribed roles. This allows the doctor and patient to work together towards the common
goal of restoring the patient to good health, despite the imbalance of power


why might a locally developed instrument be problematic in seeking patients' evaluations of hcare?

-Many local instruments do not comply with basic standards for questionnaire design
- Many do not have proven reliability and validity
- Often find higher levels of satisfaction than published instruments
- Lack of comparability


what is professionalisation?

the social and historical process that results in an occupation becoming a profession


what is a professional?

member of a profession-may or may not involve formal registration


what is a profession?

type of occupation able to make distinctive claims about its work practices and status


what 3 elements allow an occupation to become a profession?

asserting an exclusive claim over a body of knowledge/exertise
establishing control over market and exclusion of competitors
establishing control over professional work practice


describe the professionalisation of medicine

3 elements:
- asserting an exclusive claim over a body of knowledge/expertise- only people within medical profession should know this particular knowledge, only legal for them to, initially were an elite group that only catered for the wealthy
- establishing control over market and exclusion of competitors, so only those with desired knowledge are able to enter the profession
- establishing control over professional work practice- so nobody outside of the profession should be able to tell professionals what to do- occurred previously with professional self-regulation where interests of profession seen as best guarantee of interests of public and heavily dependent on profess norms as not perspective from outside


describe impact of GMC on professionalisation of medicine

limited professional self-regulation as was the beginnings of registration of drs under the 1858 Medical Act. Controlled and removed from medical register, approved and inspected medical schools, doctrine of clinical autonomy- only drs had enough expertise to montior and control the work of other drs


describe what socialisation into the medical profession involves

medical education- help turn lay person into professional
not just learning facts but also certain values and attitudes- may be learnt implicitly
not just about gaining technical competence
more than accumulating knowledge- must develop part orientations to patients and colleagues
occurs through interaction with others-both formal and informal curriculum, where formal- knowledge tested by exams, informal- attitudes and beliefs- performance in these areas noted but not examined

for a long time, GMC assumed that all those able to enter medical profession could be assumed to be of good competence and character


why is self-regulation claimed to be a right for professionals?

such an unusual degree of skill and knowlege involved that non-professionals not equipped to evaluate or regulate it
claimed that professionals are repsonsible- can be trusted to work conscientiously without supervision
profession itself can be trusted to undertake proper regulatory action on those rare occasions where someone doesn't perform their work competently or ethically


criticisms of self-regulation?

bad apple enquiries e.g. bristol enquiry: highlighted failure of those in postitions of authority in the NHS, or in the regulators, to detect signs of unacceptable or incompetent professional behaviour and to take effective and timely action to protect patients
control mostly informal- quiet chats, diverting patient flow
rules on professional propriety- drs discouraged from raising concerns about each other, shared sense of personal vulnerability, problems of quality of evidence and absence of supportive processes


describe GMC in terms of end of self-regulation

GMC has a parity of lay and professional members, all appointed independently, and overseen by council for hcare regulatory excellence- professional standards authority for health and soc care
civil rather than criminal standard of proof
sweeping reform of processes


how has the GMC changed to alter the regulation of medical professionals?

initially given power over registration of drs by the 1858 medical act, but its remit was confined to serious professional misconduct and it was reluctant to become involved in clinical matters. what was as serious misconduct tended not to reflect patient's interests. 1993 publ of tomorrow's drs significant, and from . 1997 GMC given jurisdiction to consider whether a dr's standard of professional performance was seriously deficient. primary role of GMC= to protect patients.
GMC failed to develop satisfactory system of revalidation so government took over, white paper 2007.
previously stayed on register unless actively removed, but now revalidation every 5 yrs, based on values and principles of Good Medical Practice


aims of revalidation?

assure patients
maintain and improve practice
provide support to drs in keeping their practice up to date
indetify concerns about drs at an early stage
encourage patient fback
act as a driver for improving clinical governance at local level and improve standards of care


what is clinical autonomy?

freedom to make decisions on the basis of professional judgement and specialist knowledge


why do people use complementary therapies?

symptoms persistent and not relieved with conventional tment
real or perceived adverse effects of conventional tments
prefer holistic approach to problem
may feel receive more time and attention


patients' perspectives on complementary therapies?

increasing availability and demand
high levels of satisfaction reported
Some common concerns:
– Safety and competence
– Guilt – e.g. fighting cancer
– Denial
– Cost
– Social factors – inequalities in ability to afford it


drs' persepectives on complementary therapies?

believe some established forms may benefit
BUT concerns:
unqualified and unregulated practioners
refusal of conventional tments
delayed diagnoses or missed
waste money on ineffective tments
mechanism of some therapies so implausible that it cannot work


why can it be difficult to conduct scientific studies on complementary therapies?

Resources – who will fund? (not big pharmaceuticals)
Trial of single intervention may not reflect reality
Multifaceted intervention trial very complex
Agreement to randomisation
Finding placebos/shams is challenging
Difficult to make double-blind


why might complementary therapies not be an appropriate use of resources?

not a good evidence base behind them
money spent on aromatherapy rather than chemotherapy in cancer?


arguments for NICE evaluating complementary therapies?

high public interest
half GPs provide access
address inequalities in access/opportunity
should apply same standards
stimulates more/higher quality research


arguments against NICE evaluating complementary therapies?

NHS money limited
NICE has higher priorities
poor quality evidence


problem of using EBM in complementary therapies

issue of assessing effectiveness in ways consistent with EBM principles, most evidence from complementary is qualitative
is it relevant and applicable to complementary therapies
whose evidence counts
what about evidence based on tradition and experience


4 approaches to understanding the patient-professional relationship?

first 3 are explanatory, and last is aspirational


describe the roles and duties of the sick role in the functionalsit appraoch to patient-dr relationship

sick person in state of helplessness, only a dr has technical competence to help them
sick person enters social role when ill, with right to staying of work and lack of social responsibilities, snf now in state of dependence
duty to want to get well, must not abuse their exemption, and expected to present to medical services and adhere to tment


criticisms of fucntionalist approach to patient-profess relationship?

assumes patients incompetent and have passive role
doesn't explain why things go wrong
sick role not well though out- chronic illness patient can't get better
assumes rationality and beneficence of medicine


describe conflict approach to patient-profess relationship

dr is gatekeeper- dictate patient's life to them, hold beaurcratic power
lay ideas marginilised and discounted
medicine can pathologise aspects of social life


criticisms of conflict approach to patient-profess relationship

patients not always passive e.g. control exerted by not taking medication, using complementary therapies
patients can also seek to medicalise issues
is portrayel of pat and drs as inevitably in conflict accurate?


describe interpretive approach to patient-profess relationship

focus on meaning that both parties give to encounter
focus on patterns- how does order emerge through interactions


benefits of patient-centered consultation?

patient's more likely to adhere to tment
enhances prevention and health promotion
seeks integrated understanding of patient's world
enhances continuing relationship between patient and dr so mroe likely patient will approach dr with problems
mutually agree management so dr works with patient to improve outcomes


key aspects of patient-cenetered approach to patient-profess relationship?

aspirational model
shared decision making
egalitarian relationship
patient's views taken seriously- concerns addressed
tment decision made which both dr and patient agree on after both expressing their tment preferences


what is the policy background to the growth of interest in patients' views of health services?

NHS Plan (2000)
 An account of patients’ views and the action taken as a result. Published annually.
Involving patients and the public in healthcare published by DOH (2001)- builds on the patient prospectus as a formal response to the Bristol enquiry.
NHS Act 2006: Health authorities and trusts must “involve and consult” patients and the public (2006)- Decisions about the planning, developing and considering changes in the way services are provided.


what is PALS?

Patient Advice and Liaison Services
o On the spot help about health services.
o Listen to patients’ concerns, suggestions and experiences
o Provide an early warning system by identifying problems or gaps in services
o Provide information about the NHS complaints procedure


why are quantatitive methods used more commonly than qualitative for seeking patient's views?

anonymity more easily guaranteed
relatively cheap and easy to conduct
less staff training required
facilitates monitoring of performance


What can cause dissatisfaction in healthcare?

Things that cause dissatisfaction include:
o Poor communication from health professionals: Patients not allowed to report concerns fully on their own terms
Full history of presenting complaint not taken
Reassurance not conveyed
Appropriate advice not provided
content of hcare:
Inconvenience, waiting times
“Hotel” aspects of care
Culturally inappropriate care
Health outcomes


advantages and disadvantages of using patient-based outcomes to assess dr's performance?

o Ultimately care is provided to patients, so they should feel it is adequate
o Patients may not provide an objective view. As they are the patient, their view will naturally be a selfish one as they look to improve their own care.
o Not applicable on the national scale.


why might a patient-centered approach to care not be a good thing?

some patients e.g. elderly, want dr to tell them what to do and don't want to be asked for their opinion.
not always the time available in consultations to find out about all patient views so dr will direct questionning towards specific views which means that dr and patient aren't completely equal in their roles.